Category Archives: Prediabetes

“Fewer than 1% of U.S. teens have diabetes, but nearly 18% have pre-diabetes, according to a new analysis of data from the National Health and Nutrition Examination Survey (NHANES).Researchers tested 2,606 adolescents, ages 12 to 19, for diabetes and found that the weighted prevalence was 0.8%, of which 28.5% of cases were undiagnosed, according to Andy Menke, PhD, of Social & Scientific Systems in Silver Spring, Md., and colleagues.”

Prediabetes tends to progress into type 2 diabetes over time. We don’t know much about stopping that in adolescents. I bet these steps would help:

If you’re overweight or obese, lose excess fat weight. How much should you lose? Aim for at least 5% of body weight and see if that cures your prediabetes. For instance, if you weigh 200 lb (91 kg), lose 10 lb (4.5 kg).

If you’re sedentary, start exercising regularly.

Cut back on your consumption of sugar-sweetened beverages, other sugar sources, and other refined carbohydrates like wheat flour.

Prediabetes can be defined as having hemoglobin A1c, a blood test, of 5.7 to 6.4%. We usually consider accumulation of fat around the abdomen to be a risk factor for prediabetes and type 2 diabetes. The study at hand (link below) didn’t find this to be the case in adults who were at a “healthy weight” defined as Body Mass Index of 18.5 to 24.9.

For this population, we need to identify other modifiable factors that predispose to type 2 diabetes, such as physical inactivity, lack of muscle mass, poor diet, and environmental toxins.

“PURPOSE Trends in sedentary lifestyle may have influenced adult body composition and metabolic health among individuals at presumably healthy weights. This study examines the nationally representative prevalence of prediabetes and abdominal obesity among healthy-weight adults in 1988 through 2012.”

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I got an email a few days ago from a blog reader, J.H. (I won’t give his name because I didn’t ask permission to publish his letter):

Dr. Parker — I’m a 65 year old male who has battled insulin resistance and pre-diabetes for many years. About 15 months ago I started pursuing a very low carb (20 grams per day) ketogenic diet, and my health has improved significantly. I’ve lost about 35 lbs (down from 265), and I have not found it difficult at all to stay on this regimen. You mentioned in an article (https://diabeticmediterraneandiet.com/ketogenic-mediterranean-diet/) that you don’t believe people can stay with it for more than 6 months and that most people can only last about two weeks. With all due respect, hogwash! I was fortunate enough to become a patient of Eric Westman at Duke, and he does an excellent job of teaching the ketogenic diet to his patients. Any overweight person should give it great consideration, and it’s just not that hard to follow.

Best regards, J.H.

My response was: “Congrats on a job well done! I wish all my patients had your discipline and commitment.”

I have great respect for Dr. Westman. He’s the c0-author of The New Atkins for a New You. I reviewed it in 2010. No clinical studies have compared the effectiveness of Dr. Westman’s diet to my Ketogenic Mediterranean Diet, which attempts to lasso the health benefits of the time-honored traditional Mediterranean diet while helping folks lose weight. The Ketogenic Mediterranean Diet is a key component of Conquer Diabetes and Prediabetes.

“Our genes and our environment are kind of on a collision course,” said Dr. Francine Kaufman, the former head of the American Diabetes Assn., who was not involved with the research. “It’s not stopping.”

The problem with prediabetes is that it often evolves into full-blown diabetes. It’s also associated with increased risk for cardiovascular disease such as heart attack and stroke. The Times article says “up to 70% of those with prediabetes develop diabetes in their lifetime.” I’d never heard that vague number before; I say vague because “up to 70%” could be anything between zero and 70. It’s more accurate to note that one in four people with prediabetes develops type 2 diabetes over the course of three to five years.

If you’re overweight or obese, lose excess fat weight. How much should you lose? Aim for at least 5% of body weight and see if that cures your prediabetes. For instance, if you weigh 200 lb (91 kg), lose 10 lb (4.5 kg).

If you’re sedentary, start exercising regularly.

Cut back on your consumption of sugar-sweetened beverages, other sugar sources, and other refined carbohydrates like wheat flour.

Investigators affiliated with universities in Italy and Greece wondered about the effect on obesity of two ketogenic “Mediterranean” diet spells interspersed with a traditional Mediterranean diet over the course of one year. They found significant weight loss, and perhaps more importantly, noregain of lost weight over the year, on average.

This was a retrospective review of medical records of patients of a private nutritional service in three fitness and weight control centers in Italy between 2006 and 2010. It’s unclear whether patients were paying for fitness/weight loss services. 327 patient records were examined. Of these, 89 obese participants met the inclusion and exclusion criteria and started the program; 68 completed it and were the ones analyzed. (That’s not at all a bad drop-out rate for a year-long study.) The completers were 59 males and 12 females (I know, the numbers don’t add up, but that’s what they reported). Ages were between 25 and 65. Average weight was 101 kg (222 lb), average BMI 35.8, average age 49. All were Caucasian. No diabetics.

Here’s the program:

20 days of a very-low-carb ketogenic diet, then

20 days of a low-carbohydrate non-ketogenic diet for stabilization, then

4 months of a normal caloric Mediterranean diet, then

repeat #1 and #2, then

6 months of a normal caloric Mediterranean diet

In the ketogenic phases, which the authors referred to as KEMEPHY, participants followed a commercially available protocol called TISANOREICA. KEMEPHY is combination of four herbal extracts that is ill-defined (at least in this article), with the idea of ameliorating weakness and tiredness during ketosis. The investigators called this a ketogenic Mediterranean diet, although I saw little “Mediterranean” about it. They ate “beef & veal, poultry, fish, raw and cooked green vegetables without restriction, cold cuts (dried beef, carpaccio and cured ham), eggs and seasoned cheese (e.g., parmesan).” Coffee and tea were allowed. Items to avoid included alcohol, bread, pasta, rice, milk, and yogurt. “In addition to facilitate the adhesion to the nutritional regime, each subject was given a variety of specialty meals constituted principally of protein and fibers. “These meals (TISANOREICA) that are composed of a protein blend obtained from soya, peas, oats (equivalent to 18 g/portion) and virtually zero carbohydrate (but that mimic their taste) were included in the standard ration.” They took a multivitamin every morning. Prescribed carbohydrate was about 30 grams a day, with macronutrient distribution of 12% carb, 36 or 41% protein, and 51 0r 52% fat. It appears that prescribed daily calories averaged 976 (but how can that be prescribed when some food items are “unrestricted”?).

After the first and second active weight loss ketogenic phases, participants ate what sounds like a traditional Mediterranean diet. Average prescribed macronutrient distribution was 57% carbohydrate, 15 % protein, and 27% fat. Wine was allowed. It looks like 1800 calories a day were recommended.

Food consumption was measured via analysis of 3-day diaries, but you have to guess how often that was done because the authors don’t say. The results of the diary analyses are not reported.

What Did They Find?

Most of the weight loss occurred during the two ketogenic phases. Average weight loss in the first ketogenic period was 7.4 kg (16 lb), and another 5.2 kg (11 lb) in the second ketogenic period. Overall average weight loss for the entire year was 16.1 kg (35 lb).

Average systolic blood pressure over the year dropped a statistically significant 8 units over the year, from 125 to 116 mmHg.

Over the 12 months, they found stable and statistically significant drops in total cholesterol, LDL cholesterol (“bad cholesterol”), triglycerides, and blood sugar levels. No change in HDL cholesterol (“good cholesterol”).

Liver and kidney function tests didn’t change.

The authors didn’t give explanations for the drop-outs.

Although the group on average didn’t regain lost weight, eight participants regained most of it. The investigators write that “…the post dietary analysis showed that they were not compliant with nutritional guidelines given for the Mediterranean diet period. These subjects returned to their previous nutrition habits (“junk” food, high glycaemic index, etc.) with a mean “real” daily intake of 2470 Kcal rather than the prescribed 1800 Kcal.”

Comments

A key take-home point for me is that the traditional Mediterranean diet prevented the weight regain that we see with many, if not most, successful diets.

However, most formulas for calculating steady state caloric requirements would suggest these guys would burn more than the 1800 daily calories recommended to them during the “normal calorie” months. How hard did the dieters work to keep calories around 1800? We can only speculate.

Although the researchers describe the long periods of traditional Mediterranean diet as “normal caloric,” they don’t say how that calorie level was determined and achieved in the real world. Trust me, you can get fat eating the Mediterranean diet if you eat too much.

I’ll be the first to admit a variety of weight loss diets work, at least short-term. The problem is that people go back to their old ways of eating regain much of the lost weight, typically starting six months after starting the program. It was smart for the investigators to place that second ketogenic phase just before the typical regain would have started!

There are so few women in this study that it would be impossible to generalize results to women. Why so few? Furthermore, weight loss and other results weren’t broken down for each sex.

I suspect the results of this study will be used for marketing KEMEPHY and TISANOREICA. For all I know, that’s why the study was done. We’re trusting the investigators to have done a fair job choosing which patient charts to analyze retrospectively. They could have cherry-picked only the good ones. Some of the funding was from universities, some was from Gianluca Mech SpA (what’s that?).

How much of the success of this protocol is due to the herbal extracts and TISANOREICA? I have no idea.

The authors made no mention of the fact the average fasting glucose at baseline was 103 mg/dl (5.7 mmol/l). That’s elevated into the prediabetic range. So probably half of these folks had prediabetes. After the one-year program, average fasting glucose was normal at 95 mg/dl (5.3 mmol/l).

The improved lipids, blood sugars, and lower blood pressure may have simply reflected successful weight loss and therefore could have been achieved by a variety of diets.

The authors attribute their success to the weight-losing metabolic effects of the ketogenic diet (particularly the relatively high protein content), combined with the traditional Mediterranean diet preventing weight regain.

The authors write:

The Mediterranean diet is associated with a longer life span, lower rates of coronary heart disease, hypercholesterolemia, hypertension, diabetes and obesity. But it is difficult to isolate the “healthy” constituents of the Mediterranean diet, since it is not a single entity and varies between regions and countries. All things considered there is no “one size fits all” dietary recommendation and for this reason we have tried to merge the benefits of these two approaches: the long term “all-life” Mediterranean diet coupled with brief periods of a metabolism enhancing ketogenic diet.

The moderator asked his experts twice whether carbohydrate restriction is important, and never got a straight answer. These experts must not think it’s important since they push legumes, lentils, fruits, and whole grains. Dr. Nadeau said he believes there is no specific diet for folks with diabetes. I almost fell off my chair when I read one comment recommending cookies and sweets, because they’re traditional. They also recommend low glycemic load, nuts, higher protein consumption, vegetables, and “good oils” like olive oil (ghee not mentioned).

I’m confident that Dr. Ronesh Sinha in Silicon Valley, California, would disagree with the advice of MedPageToday’s experts. Dr. Sinha would likely recommend limiting digestible carbohydrates to 50–150 grams/day as the most important dietary step. (I plan on a review of Dr. Sinha’s book here within a few months.)

I’m still looking for clinical studies of various diets for South Asians (aka Indian Asians) with prediabetes and diabetes.

Thirty-four overweight and obese type 2 diabetics (30) and pre diabetics (4) were randomly assigned to one of the two diets:

MCCR: American Diabetes Association-compliant medium-carbohydrate, low-fat, calorie-resticted carb-counting diet. The goals were about 165 grams of net carbs daily, counting carbohydrates, an effort to lose weight by eating 500 calories/day less than needed for maintenance, and 45–50% of total calories from carbohydrate. Protein gram intake was to remain same as baseline. (Note that most Americans eat 250–300 grams of carb daily.)

LCK: A very-low-carbohydrate, high-fat, non-calorie-restricted diet aiming for nutritional ketosis. It was Atkins-style, under 50 grams of net carbs daily (suggested range of 20–50 g). Carbs were mostly from non-starchy low-glycemic-index vegetables. Protein gram intake was to remain same as baseline.

Baseline participant characteristics:

average weight 100 kg (220 lb)

25 of 34 were women

average age 60

none were on insulin; a quarter were on no diabetes drugs at all

most were obese and had high blood pressure

average hemoglobin A1c was about 6.8%

seven out of 10 were white

Participants followed their diets for three months and attended 13 two-hour weekly classes. Very few dropped out of the study.

Results

Average hemoglobin dropped 0.6% in the LCK group compared to no change in the MCCR cohort.

A hemoglobin A1c drop of 0.5% or greater is considered clinically significant. Nine in the LCK group achieved this, compared to four in the MCCR.

The LCK group lost an average of 5.5 kg (12 lb) compared to 2.6 kg (6 lb) in the MCCR. The difference was not statistically significant, but close (p = 0.09)

44% in the LCK group were able to stop one or more diabetes drugs, compared to only 11 % in the other group

31% in the LCK cohort were able to drop their sulfonylurea, compared to only 5% in the MCCR group.

By food recall surveys, both groups reported lower total daily caloric intake compared to baseline. The low-carbers ended up with 58% of total calories being from fat, a number achieved by reducing carbohydrates and total calories and keeping protein the same. They didn’t seem to increase their total fat gram intake;

The low-carbers apparently reduced daily carbs to an average of 58 grams (the goal was 20-50 grams).

There were no differences between both groups in terms of C-reactive protein (CRP), lipids, insulin levels, or insulin resistance (HOMA2-IR). Both groups reduced their CRP, a measure of inflammation.

LCK dieters apparently didn’t suffer at all from the “induction flu” seen with many ketogenic diets. They reported less heartburn, less aches and pains, but more constipation.

Hypoglycemia was not a problem.

If I recall correctly, the MCCR group’s baseline carb grams were around 225 g.

Bottom Line

Very-low-carb diets help control type 2 diabetes, help with weight loss, and reduce the need for diabetes drugs. An absolute drop of 0.6% in hemoglobin A1c doesn’t sound like much, translating to blood sugars lower by only 15–20 mg/dl (0.8–1 mmol/l). But remember the comparator diet in this study was already mildy to moderately carbohydrate-restricted. At least half of the type 2 diabetics I meet still tell my they don’t watch their carb intake, which usually means they’re eating around 250–300 grams a day. If they cut down to 58 grams, they most likely will see more than a 0.6% drop in hemoglobin A1c after switching to a very-low-carb diet.

This is a small study, so it may not be reproducible in larger clinical trials and other patient populations. Results are consistent with several other similar studies I’ve seen, however.